A Diamond DA40 NG light aircraft’s loss of control and collision with terrain just south of Port Macquarie Airport highlights the need to maintain aircraft control in the event of an emergency or abnormal situation, an ATSB investigation notes.

On the evening of 8 September 2017, an instructor and student were preparing to conduct the student’s first series of night circuits, with the instructor at the controls for the first take-off. At about 200 feet above the runway, the instructor observed propeller speed and engine power fluctuations that continued to increase as the aircraft climbed to 400 feet.

Recorded data would show that the engine was producing full power, however, the instructor interpreted the noise and vibrations brought on by the propeller fluctuations as a partial engine power loss and commenced a left turn, aiming to return and land on the runway in the opposite direction to the take-off.

The instructor had considered landing straight ahead but assessed that there was power available to turn and that they would be unable to see and avoid trees or to be sure to land in a suitable clearing ahead.

In the 10 seconds that the instructor was assessing and making decisions about a perceived partial power loss, the airspeed reduced from 75 to 69 knots due to the aircraft’s nose-up attitude. Then, at the same time as commencing the turn back towards the runway, the instructor reduced engine power to 30 per cent, while maintaining a nose-up attitude, and airspeed reduced rapidly.

During the turn, the aircraft stalled, resulting in a loss of control. Although the aircraft pitched down and the instructor subsequently increased power, control was not regained. The aircraft descended and collided with trees, coming to rest inverted.

The student and instructor were seriously injured, and the aircraft was destroyed.

The ATSB’s investigation into this accident found after reducing power, the instructor did not maintain adequate airspeed during the turn. This resulted in the aerodynamic stall and loss of control.

The aircraft manufacturer, Diamond Aircraft Industries, could not determine the reason for the fluctuations. Propeller speed fluctuations had occurred in other DA40 NG aircraft, and either resolved without pilot input or by moving the power lever.

“This investigation highlights three initial actions that pilots should consider to maintain aircraft control in the event of an emergency or abnormal situation, such as in this accident, which was a perceived partial power loss after take-off,” said ATSB Director Transport Safety Dr Stuart Godley.

“Firstly, lower the nose to maintain the glide speed of the aircraft, and if turning, pilots need to keep in mind an increased bank angle will increase the stall speed.  

“Secondly, maintain glide speed and assess whether the aircraft is maintaining, gaining or losing height to gauge current aircraft performance.
 
“Finally, fly the aircraft to make a landing, given the aircraft’s height and performance, and the pre-planned routes for the scenario.”

Read the final report: Loss of control and collision with terrain involving Diamond DA40, VH-YPQ, 1 km south of Port Macquarie Airport, New South Wales, on 8 September 2017

Further details of the research are included in the ATSB research report’s Avoidable Accidents No. 3 – Managing partial power loss after take-off in single-engine aircraft, as well as more information to assist pilots maintain aircraft control in the event of an emergency or abnormal situation.   

The loss of control and collision with terrain of a Bristell LSA aircraft clearly demonstrates the catastrophic consequences of conducting aerobatic flight in a non-aerobatic aircraft, without adequate training in the specialist techniques and methods required for maintaining aircraft control, a new ATSB report says.

On 5 October 2018, the pilot of the Bristell aircraft departed Moorabbin Airport, Victoria with the pilot and passenger on board for a navigation exercise in support of the pilot’s commercial pilot training requirements. After take-off, the flight headed over the northern part of Port Phillip Bay. Automatic Dependence Surveillance Broadcast data and on-board flight and GPS data showed the pilot commenced significant manoeuvres including steep climbs, descents and turns in excess of 90 ° angle of bank between 600‑1,300 ft above ground level (AGL) over a built up area west of Melbourne.

The aircraft then headed north-west until overhead Stawell Airport. Once past the airport, a number of witnesses saw the aircraft commence a 180° turn to the south-east followed by a series of steep climbs and turns and then abruptly enter an upright spin and descend out of view. The aircraft maintained the spinning descent until it impacted terrain. The pilot and passenger sustained serious injuries and the aircraft destroyed.

The ATSB investigation found that contrary to the aircraft’s limitations and the pilot’s qualifications, aerobatic manoeuvres were conducted during the flight, and immediately before the loss of control. The aircraft then experienced an accelerated aerodynamic stall and entered into an upright, fully‑developed spin. Although the pilot did not consistently apply the manufacturer’s recommended spin recovery technique, recovery from a fully‑developed spin may not have been possible in aircraft types not approved for spinning.

The ATSB safety message from the investigation emphasises that aerobatic flight should not be undertaken by pilots who are not been adequately trained, as it requires specialist techniques and methods to maintain control of the aircraft during significant manoeuvring.

In addition, pilots need to be aware that when the aircraft manufacturers stipulate flight limitations and prohibit aerobatics in their aircraft types, this means the aircraft has not been designed or tested to ensure these manoeuvres can be done safely. Related warnings, advice and instructions need to be followed.

The aircraft’s data recording system was integral in determining the magnitude of the aerobatic manoeuvres during the accident flight. They can also be a readily accessible tool for both flying training and maintenance.  

The ATSB identified that the operator had not installed an optional SD back up memory card for the aircraft’s Garmin G3X integrated instrument and avionics system. Therefore, had the avionics unit been damaged valuable data could have been lost.

Aircraft owners are encouraged to make themselves aware of the data recording capability of their aircraft and ensure that the systems are fully functioning and backing up information.

Read the report: Loss of control and collision with terrain involving BRM Aero S.R.O Bristell LSA aircraft, VH-YVX, at Stawell, Victoria, on 5 October 2018

A freight train unexpectedly encountered and entered floodwaters across a rail bridge near Tully, Queensland, highlighting the importance of weather monitoring stations at known flood locations being serviceable, a new ATSB report says.  

Intermodal Aurizon freight train 6792 had departed Cairns for Brisbane early morning on 7 March 2018, with a ‘condition affecting network’ (CAN) declared for wet weather and a requirement to run at ‘controlled speed’—requiring that the train be able to stop short of an obstruction within half the distance of clear line that was visible ahead—for a significant amount of the journey.

Approaching the Little Banyan Creek rail bridge, near Tully, the driver saw floodwater covering the bridge and immediately attempted to stop the train by applying the emergency brake. However, the train was unable to stop in the distance available, and it entered the water.

Neither of the train crew were injured, and after consulting with the network control officer and the crew’s supervisor, the driver moved the train forward at low speed through the floodwater and into Tully yard.

The ATSB investigation found that the Little Banyan Creek weather monitoring station’s water level sensor had been out of service for several weeks and could not provide a flood warning to network control to pass on to the crew. Further, a closed circuit television camera for monitoring water levels was also ineffective at night due to an out-of-service illuminator.

The investigation also found that the rail infrastructure operator, Queensland Rail (QR), did not have an effective means of ensuring that, during situations such as a CAN, network control personnel were aware of the relevant weather monitoring systems that were unserviceable. Control personnel were also not required to actively search for information about track conditions ahead of a train during situations when conditions had the realistic potential to have deteriorated since the last patrol or train had run over a section.

The investigation also identified issues with the application of the controlled speed restriction, and the management of workload during two-driver operations during a CAN.

“This investigation highlights the importance of having serviceable weather monitoring stations at known flooding locations on a rail network, and ensuring that if these systems are not functioning all relevant parties need to be aware of the defect,” said ATSB Director Transport Safety Dr Mike Walker.

“Further, operating under a CAN requires effective communication between all relevant parties. Train controllers need to ensure that all relevant information associated with the network conditions are passed to train crews and track maintenance personnel so that they can effectively perform their roles.”

Following the incident QR made improvements to its processes for ensuring the reliability of weather monitoring systems, as well as to its procedures for ensuring network control personnel were aware of any faults. It has also developed new procedures and training for network control personnel to proactively monitor network conditions when managing a CAN.

Read the final report: Collision with floodwater involving freight train 6792, Little Banyan Creek, Queensland, on 7 March 2018

The derailment of a freight train wagon following a ruptured wheel in the wagon’s ‘B’ end wheelset highlights potential limitations of field inspections for the detection and monitoring of fatigue cracks, a new ATSB investigation says.

SCT Logistics freight train 6MP9 was travelling from Melbourne to Perth early on the morning of 4 January 2019. While on the Fisher-Thomair section of track near Cook, South Australia, a single wagon derailed due to a ruptured wheel. While no other wagons derailed, damage to sleepers and clips was found in the area of the derailment

Prior to the derailment, the train had passed over two wayside detectors designed to alert the operator of abnormalities that might indicate wheel or bearing damage. However, there was no record of any alerts received from these detectors.

While vigilant field inspections are a useful tool for the detection and monitoring of fatigue cracks, they are not infallible and should be used with an understanding of their limitations.

ATSB Director Transport Safety, Stuart MacLeod said the derailment was due to fatigue cracking in the ruptured wheel.

“Metallurgical examination found a fatigue crack had initiated in the wheel flange and then propagated into and around the wheel plate and rim, causing the wheel to fail and break into multiple pieces,” Mr Macleod said.

“The fatigue crack was found to have initiated in an area of the wheel that showed signs of sliding contact with the rails. Sliding contact can cause thermal damage to the wheel leaving a white etching layer that is brittle and more susceptible to cracking.” 

Mr Macleod noted that at the last inspection, the flange fatigue crack was likely observable but was either not detected, or was deemed acceptable under the work instruction provided. This work instruction provided guidance that was less conservative than the Australian Standard, but it was not possible to establish whether compliance with the standard would have prevented the occurrence.

 “This incident demonstrates that while vigilant field inspections are a useful tool for the detection and monitoring of fatigue cracks, they are not infallible and should be used with an understanding of their limitations,” Mr Macleod said.

“Further, selection of the appropriate materials for wheels can also assist in reducing the occurrence of fatigue cracks and subsequent failures.”

Since the incident the operator has worked with its maintenance provider to develop an improved inspection process for wheels exhibiting brakes issues, particularly sticking brakes, an issue known to lead to the development of thermal cracking.

The operator is also phasing out the ruptured wheel class type from its fleet.

Read the final report: Derailment of SCT Logistics freight train 6MP9, near Cook, South Australia, on 6 January 2019

The Australian Transport Safety Bureau has issued a Safety Advisory Notice to commercial hot air balloon operators recommending they review their operational practices to reduce the risk of passenger injury when using vehicles to assist with balloon deflations. 

The Safety Advisory Notice arises from an ATSB investigation into a 16 March 2019 incident near Coldstream, Victoria where two passengers sustained injuries when the basket of a Kavanagh B-400 balloon operated by Picture this Ballooning tipped over when a vehicle was being used to assist the deflation of the balloon envelope.

Due to the lack of wind and the large size of the envelope, after the completion of a scenic flight the crew elected to use the recovery vehicle to assist in pulling the envelope over during deflation by attaching the crown line—a rope attached to the top or crown of the balloon—to the vehicle then slowly driving forward.

During this process, with 16 passengers and the pilot on board, the vehicle inadvertently pulled the basket over, resulting in one passenger sustaining broken ribs and another being knocked unconscious.

The ATSB’s investigation into the accident found that the operator had not conducted a risk assessment concerning the use of vehicle-assisted deflations.  

The ATSB advises all commercial balloon operators utilising vehicle‑assisted deflation to review their current operational practices with the aim of mitigating the safety risks associated with the procedure. 

ATSB Director Transport Safety Dr Stuart Godley said while not required by regulation, the lack of a risk assessment for vehicle-assisted deflation likely left the operator and crew unaware of the risks associated with the process and without appropriate procedures to control those risks.

“As a result, when communication broke down between the pilot and vehicle driver leading to the basket tipping over, the passengers were unprepared and not in the landing position, increasing their likelihood of injury.”

This accident was the third time in Australia since 2016 where occupants of a commercial balloon have been injured during a vehicle‑assisted deflation, prompting the ATSB to issue a Safety Advisory Notice regarding the practice.

“The ATSB advises all commercial balloon operators utilising vehicle‑assisted deflation to review their current operational practices with the aim of mitigating the safety risks associated with the procedure,” Dr Godley said.

The number of large hot air balloons with envelopes of 350,000 cubic feet or greater registered in Australia has increased by around eight to nine balloons each year since mid-2015, the ATSB notes (the B-400 has a 400,000 cubic foot envelope and is certified to carry up to 22 passengers and crew).

“The average size of these larger balloons has also increased resulting in a corresponding increase in the number of passengers per balloon flight, making it likely that the number of passengers at risk of injury will also increase,” said Dr Godley.

“Regulatory guidance on the mitigation of the potential risk from vehicle-assisted deflations will be important to help educate commercial balloon operators and assist them to mitigate risk as the number of passengers in these larger balloons continues to increase.”  

The Civil Aviation Safety Authority has advised the ATSB of their intention to produce an advisory circular on deflation of hot air balloon envelopes using vehicle assistance.

Meanwhile, the operator has developed and implemented a new vehicle-assisted deflation procedure with improved communication instructions for pilots and ground crew.

Read the final report: Ground handling event involving Kavanagh B-400 Balloon, VH-LNB, near Coldstream, Victoria, on 16 March 2019

Read the ATSB's safety advisory notice: Potential for injury during vehicle-assisted deflation.

An incident where a tourism operator’s airboat struck a tree during a ‘hot lap’ as part of a wetlands tour, resulting in minor injuries to passengers and the driver, emphasises the importance of risk assessments and safety management systems, a new ATSB reports says.

The airboat Gale Force, with a driver and four passengers onboard, was operating a ‘hot lap’ as part of a wetlands tour of Sweets Lagoon, about 55 km south-west of Darwin, on 22 June 2019.

A few minutes into the tour, the airboat was at speed when the track into a turn to starboard was slightly misjudged and control was lost. The airboat’s stern swung to port and left the channel. The starboard aft corner of the airboat swung round and struck a tree a few metres from the water’s edge.

The impact threw the occupants backwards and then, as momentum swung the bow round, they were propelled forward, out of their seats. The skipper was injured and dazed from being thrown against the airboat side cage. The passengers sustained varying degrees of injury, including cuts and bruising, depending on where they were seated.

The ATSB investigation into the incident identified that operational limitations, such as speed, which would have reduced the likelihood of the collision and resultant injuries, were not fully identified by the operator’s risk assessments and therefore unable to be implemented through their safety management system following a shift in the operator’s focus away from ‘adrenaline‑based’ activity such as ‘hot laps’. 

“Tourism operators who undertake activities such as airboating that involve fare-paying passengers should carefully and regularly assess their operations for risk,” said ATSB Director Transport Safety Stuart Macleod.

“In this instance, operational limitations which would have reduced the likelihood of the collision and reduced the injury consequences had not been fully identified and implemented.”

Since the incident the airboat operator has updated its safety management system’s procedures and requirements. Specific airboat training, guidance and competency requirements have been implemented, and emergency procedures have been updated.

Read the final report: Collision with a tree involving the airboat Gale Force, Sweets Lagoon, Northern Territory, on 22 June 2019

A catamaran ferry crew’s response to a suspected engine room fire reinforces the importance of vessel operators having robust procedures and training, a new ATSB investigation has stressed.

On 29 March 2019, the catamaran ferry Fitzroy Flyer was on a scheduled transfer between Cairns and Fitzroy Island, with four crewmembers and 37 passengers on board. About halfway into the 50-minute journey, at about 2:10pm, the port main engine overheated, activating a fire alarm on the bridge.

A crewmember and a passenger (who was a former firefighter) investigated and reported sighting smoke and fire. Initial attempts were made to extinguish the fire using portable extinguishers, but the crew could not confirm if those attempts were successful in extinguishing any fire. The presence of a fire was unable to be confirmed and, after taking advice from shore management, the master subsequently activated the port engine room fire suppression system.

Meanwhile, all passengers were mustered to the bow of the vessel, and were subsequently evacuated onto two nearby vessels. The master then started the starboard engine and the Fitzroy Flyer slowly returned to Cairns, where it safely berthed without further incident.

Inspections carried out after the incident found no evidence of a fire or any fire damage in the engine room. Instead, the smoke and fire seen by the crew were likely from a loose and slipping fan drive belt and steam from the overheated cooling system.

The ATSB found that the crew’s response to the fire alarm did not follow company procedures as they had practised during emergency drills. This included not promptly activating the vessel’s fire suppression system or applying boundary cooling, and making several entries to the port main engine room without suitable risk controls in place.

In addition, the passengers were transferred in open waters and without lifejackets to two other vessels with varying freeboards, at which point the engine room situation appeared to be under control, while the crew did not issue a ‘PAN PAN’ urgency message to emergency services and other vessels, informing of the Fitzroy Flyer’s status and requesting assistance.

“This occurrence highlights the importance of vessel operators having robust procedures and training for responding to fires and other emergencies on board, and for crewmembers to follow procedures and training in such situations,” said ATSB Director Transport Safety Dr Mike Walker.

“In particular, if a fire is suspected in an engine room, and further assessment is not possible, then crews should deploy the available suppression systems and transmit an urgency message.”

Since the incident, the Fitzroy Flyer’s owner-operator has updated the vessel’s safety management system, improved crewmember training, and installed a closed-circuit television camera surveillance system throughout the vessel.

Read the final report: Suspected engine room fire and passenger evacuation involving domestic commercial vessel Fitzroy Flyer, 13km east-north-east of Cairns, Queensland, on 29 March 2019

Checklists are essential for overcoming memory limitations and ensuring actions items are completed, an ATSB investigation into an incident where a tail strut was not detached from a BAe 146 freighter aircraft prior to take-off highlights.

The Cobham Aviation Services British Aerospace 146-300 had landed in Sydney in the early morning of 22 January 2019 while en route from Melbourne to Brisbane, conducting a scheduled night freight operation. The tail strut, which prevents the aircraft from tipping onto its rear fuselage during loading operations, was attached to the rear of the aircraft before cargo unloading and loading commenced.

Although confirmation of the tail strut’s removal prior to departure was a checklist item prior to engine start, the aircraft taxied for departure to Brisbane with the tail strut still attached. As it taxied, a ground crew member saw that the tail strut was still attached, however, a number of attempts to contact the flight crew were unsuccessful and the aircraft turned onto the runway and departed.

As a consequence the tail strut detached from the aircraft during the take-off roll and fell onto the runway. A subsequent runway inspection recovered the tail strut, and the aircraft continued to Brisbane and landed without further incident.

The ATSB’s investigation into the incident found that pre-departure checklist items, required to be performed by the aircraft captain and the ground engineer in a challenge-and-response manner, were not completed. This negated the value of the checklist as a risk control, and resulted in a missed opportunity to detect the tail strut’s presence prior to departure.

The ATSB also found that the engineer performing the aircraft turn-around had no effective means or procedure to contact the aircraft while it was taxiing.

In response to the incident, the operator undertook a number of actions including issuing a safety alert to relevant staff highlighting the despatch procedure, including the challenge-and-response requirement for the relevant cockpit to ground checklist.  

This investigation’s safety message highlights checklists are an essential tool for overcoming memory limitations, and ensuring that action items are completed in sequence and without omission.

The ATSB notes that while, the value of checklists may not be obvious for routinely-performed tasks, the incomplete use of checklists has often been cited as a factor in previous aircraft accidents.

Read the final report: Aircraft preparation occurrence involving BAe 146 300, VH-NJZ, Sydney Airport, New South Wales, on 22 January 2019

An Airbus A330 departed Sydney with the aircraft’s maximum take-off weight exceeded by 494 kg following a loading irregularity, an ATSB investigation details.

On 17 December 2017, a Qantas A330-300 was being loaded with freight in preparation for an international passenger flight from Sydney to Beijing, China. After landing in Beijing, the airline’s freight agent identified that the aircraft had been loaded incorrectly. As a result, the aircraft had departed Sydney 875 kg above the weight listed in the revised load sheet, and 494 kg above the aircraft's maximum take-off weight.

The ATSB found that an operational requirement for additional holding fuel resulted in the operating flight crew issuing a revised load instruction to carry less cargo. However, this instruction was not actioned and led to a 2,005 kg pallet of freight remaining on board the aircraft, instead of being replaced with a lighter unit weighing 1,130 kg.

The required cargo variation was not actioned by the load supervisor, as electronic messages associated with the revised loading instruction were acknowledged without being correctly interpreted. That action was probably influenced by the supervisor’s experience that load changes were accompanied by verbal advice, which did not occur on this occasion.

The ATSB’s investigation into the incident highlights the importance of communication between all parties responsible for aircraft loading. Planning and loading of freight in the high-capacity passenger sector is often conducted under significant time pressure, where delays can lead to scheduling issues.

Effective communication between all parties responsible for aircraft loading can assist in reducing errors, the investigation notes.

As a result of this, and other freight loading occurrences, Qantas have introduced handheld scanning devices that automate much of the freight confirmation and mobile communication process using printed barcode and scanning technology. The scanners were implemented at most domestic and international Qantas ports by June 2019.

Read the final report: Aircraft loading-related occurrence involving Airbus A330-303, VH-QPD, Sydney Airport, New South Wales, on 17 December 2017